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It will, I suspect, be a cause for wonder in times to come that we have so far forgotten what is our basic biological drive—to reproduce ourselves successfully—that even those who have chosen to devote themselves to the medical care of children have lost sight of what kind of social environment is needed to facilitate optimum growth and development. Perhaps it began with the euphemistic labelling of what is in fact predominately a national disease service, the NHS, thus allowing government to put to one side its primary duty of fostering the well being of the population, not just in economic terms (substituting means for ends) but in body, mind, and psyche. The cure of disease requires a very different approach to the care of the healthy, and our profession’s main contribution to the latter is to inform those responsible to what extent and in what respects they are failing.
It was Winnicott who pointed out the obvious truth that there is “no such thing as a baby” as its viability depends on someone else. The question is, who that someone else should be—who is best fitted to undertake the difficult and exacting task of rearing children. It can be and is argued that it does not matter, that the biological mother is no better fitted for it than the biological father or indeed a stepfather or a baby minder, grandmother or nursery nurse. Because a baby will go to anyone in the first few months of life before “it” has had the chance of forming an attachment, anyone will do providing they have a modicum of training, good sense, competence, and concern (quite a tall order in itself). It is true that the capability of conceiving and bearing a child does not always confer what it takes to rear one. In our society bottle feeding seems to be as satisfactory as breast feeding; the male psyche has its female elements and vice versa; it is not fair that the whole onus of parenting should fall on the female member of a reproductive dyad (the jargon is symptomatic), and children are by and large so resilient that if they can stay alive they are likely to turn out all right. On the other hand, Winnicott again has drawn our attention to what most women who have been mothers know at the time (he also points out that they forget it afterwards): in well pregnant and nursing women there is a period of primary maternal preoccupation, beginning in late pregnancy and lasting almost until weaning, during which her entire attention is focused on her baby, a preoccupation that is biologically determined by mechanisms that no doubt sooner or later we will come to unravel and understand. This is a state bordering on what might at another time be labelled psychosis that cannot be induced in men or initiated by women who have not arrived at the appropriate stage of gestation, and it is obviously designed by natural selection for the wellbeing of the species. Nor is this the only compelling argument for biological mothers to care for babies in the first months of their lives. We all know and can rehearse the arguments in favour of breast feeding, we can all appreciate that no one other than the biological parents can have the same interest in the wellbeing of their offspring or the same opportunities to pursue it. The evidence suggests that until a baby has formed a secure and deep relationship with one person, he or she will not be ready or even able to make others: initially with their father, siblings, etc, then with school friends, colleagues at work, etc. A baby who will go to anyone at an age when paranoia is normal, may end up going with anyone as a sexual partner in adolescence, often with disastrous consequences for all concerned.
My father once defined “experience” as finding out what we can get away with; and we can usually get away with a great deal in caring for babies whose intrinsic vitality enables them to survive and indeed grow by (as Winnicott again put it) their mothers’ mended mistakes. But getting away with it surely should not be all we aim at in rearing our young, nor should it be just the lowest possible infant mortality or morbidity rate. A farmer who treated his breeding stock as we treat our human one would soon go out of business; yet our culture (if it deserves the name) seems designed to make everything easy except childcare. While middle aged men connive at their own demise by driving when they could and should walk or cycle, women with children by and large must travel on foot to shops and parks increasingly remote from their homes, waiting in the rain for cars to pass, and often getting soaked in dirty spray as they do so. It must have been more agreeable in biblical times to make the daily trip to the well, jar on head, for a gossip with friends and the children playing in safety around them.
What about women’s careers? Everyone knows of women who have made important contributions to our subject; both those without children and those whose children have gone to school or grown up. Other paragons have somehow coped more or less successfully and happily with child rearing and working in parallel. But what we should be thinking about is the modal lifestyle and making it possible for women who choose to devote themselves (I use the term advisedly) to child rearing to do so without the opprobrium of their sisters or the sacrifice of their own aspirations. This should not necessarily involve a standard of living way below that of the rest of the population, whose pensions will be earned by other people’s children when grown up.
If our society is to survive in a worthwhile way into the next millennium, what is needed is, as Auden put it, “new styles of architecture” (a new framework in which to live, catering for our basic psychological needs in an industrial age) and a change of heart (to put first things first and ends before means). Adequate alternative care for the young children of working women is much more expensive than giving them the means to care for their own children (just as “care” costs more than Eton) and is not an appropriate response to the problems of one parent families. Could it be that what is arguablyfair for women is unfair to children; and yet no one these days except the most rigid Roman Catholics need have children if they do not fancy looking after them. Perhaps women will have to acknowledge there are biological differences between the sexes, however reinforced by social premises and customs, and that they cannot have their cake and eat it, however desirable that may seem. In what is usually a long life for most of us (boringly so for some) there is plenty of time for everything except what is euphemistically called “getting on”—the equivalent of the cock crowing on the dunghill while the hens get on with more important things. Surely if there is any purpose in setting up a College of Child Health, we should be giving a lead to the nation and in the right direction.
The Bayley developmental scales enquire of 2 year olds “are you a boy or a girl?” and go on to ask whether they will grow up into a mummy or a daddy; mercifully they do not ask whether they might become a doctor or a nurse.
Professor Davis’s caution comes to us at a time of reflection for the feminist movement and, dare I say it for female paediatricians of a certain age. Spending our teenage years in the culture of the ’60s we entered medical schools still exerting strict quotas on women entrants. The first generation to be offered the possibility of taking complete control of its sexual activity and fertility while surfing the unfolding safety profile of the oral contraceptive pill, has become the generation that can avoid hot flushes and defer osteoporosis and wrinkles at an as yet undefined cost of increased endometrial and breast cancer—a truly experimental cohort of women. In the closing years of the century we find ourselves with one of every three couples who do marry filing for divorce, and a Prime Minister with a wife with a six figure salary promoting the line that single mothers who do not go out to work should be penalised.
Women will work, and as we raise the A level requirements for entry to medical school, so we will tend to select higher numbers of girls. Furthermore, women, and I believe many of the more attractive men in medicine, will be drawn to careers in paediatrics because of their innate affection and compassion for children.
As the numbers of female consultant paediatricians has risen, it is clear that, in contrast to earlier times, most are in stable relationships and have children, albeit often delaying the latter until their career is well advanced. I am interested that Professor Davis does not say for how long he believes women should take full time care of their own children nor is it easy to obtain reliable data on the children themselves. Stories abound about problem children of clergymen, but I have yet to hear of the terrible exploits of the offspring of women doctors or indeed of any other group of women (women priests have perhaps not been with us for long enough). It is also the case that while our children might tease us and test us I am repeatedly fascinated by how the children of women who appear to have devoted exceedingly little time to them do know their own mother and have a relationship with her that is completely different from that with the “nanny” to whom cursory farewells are waved while the replacement is awaited. Perhaps the reason we do not have the social catastrophe that is threatened is that Winnicot and Professor Davis are wrong. Perhaps the period of primary maternal preoccupation is not confined to pregnancy and the weeks immediately following birth. Professor Davis is too perceptive not to have noticed the maiden paediatrician hold her tiny patient and imagine, or the mother of teenagers who thrills to discover a crying infant the nurses do not have time to feed with whom she can retreat into a corner and cradle; remembering and re-entering those long dark comforting nights of early motherhood as she dreams forward to the delights of grandchildren. Women who have studied medicine and devoted their subsequent careers to the health of children will be the last to neglect the critical needs of their own children. It is not great tracts of time that they need, but it is special time. The flexibility to be able to take a little time off at half term, to be able to be present for at least some of the end of term concert, to occasionally give a hand with homework, and to be able to stay awake for just long enough to listen as the teenage daughter creeps into bed for 10 minutes to tell of her latest love. Caring for children does not necessitate being with them all the time, but it does involve identifying time that is exclusively theirs.
I am not the least interested in whether 10%, 50% or 80% of the places on the boards of merchant banks are for women, or the numbers of brain surgeons or indeed paediatricians who are women, but I do believe passionately that women who have the ability and who aspire to such positions should have equal access, while at the same time recognising that it is essential for both sexes to be able to have children and to care for them in the way that feels right for both parents.
One of the leads that a College of Child Health should give to the nation is to ensure that we have flexibility in the pattern of employment of both our trainee and our senior workforce, so that the needs of children can be addressed in parallel with career development. Perhaps we should campaign that women who do choose to take time out in excess of the statutory period of maternity leave should not be penalised by having to buy “extra years” to receive a full pension.